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Spontaneous intracranial hypotension: Two cases including one treated with epidural blood patch
Pankaj Agarwal1, Suresh Menon, Rajan Shah
1Departments of Neurology, Bombay Hospital Institute of Medical Sciences, Mumbai, India.
Annals of Indian Academy of Neurology
|February 23, 2010
Summary
Spontaneous intracranial hypotension (SIH) can cause severe neurological symptoms. Epidural blood patches (EBPs) offer effective treatment for patients unresponsive to conservative measures, as shown in these case studies.
Area of Science:
- Neurology
- Neurosurgery
Background:
- Spontaneous intracranial hypotension (SIH) is a condition characterized by low cerebrospinal fluid (CSF) pressure, often presenting with orthostatic headache (OH) and diffuse pachymeningeal gadolinium enhancement (DPME) on MRI.
- Diagnostic challenges in SIH arise when the CSF leak is not readily identifiable.
Observation:
- Two patients with SIH presented with OH, bilateral subdural fluid collections, DPME, and brain sagging on MRI.
- One patient with a demonstrable thoracic CSF leak recovered with conservative management.
- The second patient, with an unidentified leak, developed severe encephalopathy and coma, requiring urgent intervention.
Findings:
- Urgent epidural blood patch (EBP) with 25 cc of autologous blood provided immediate and complete symptomatic relief in the comatose patient.
- A second EBP ensured complete and sustained clinical benefit without recurrence in the severe case.
- These cases highlight the diagnostic utility of recognizing orthostatic headache and characteristic MRI findings.
Implications:
- A high index of suspicion for SIH is crucial, particularly with characteristic orthostatic headache and MRI findings.
- Epidural blood patching is a highly effective therapeutic option for SIH patients refractory to conservative treatments.
- These case studies underscore the potential for rapid neurological deterioration in SIH and the critical role of timely EBP intervention.
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